Friday, July 30, 2010

Kidney transplantation advice from the Netherlands

Two recent reports from the Netherlands give advice drawn from their active transplant program.

The (American) National Guideline Clearinghouse highlights one set of recommendations: Kidney donation. In: Guidelines on renal transplantation. European Association of Urology - Medical Specialty Society. 2009 Mar. 23 pages. NGC:007337 (full text here.)

The first three recommendations under the first category of recommendations, "Ethical Issues in Transplantation," illustrate some of the conflicting forces at work:

  • "It is the right of individuals to donate as well as to receive an organ.
  • "Commercially motivated renal transplantation is unacceptable. It has been widely prohibited by law and is strongly opposed by the International Society of Transplantation.
  • "With the increasing success of living-donor transplants, as judged by graft and patient survival, and with the scarcity of deceased donor organs, living-donor transplants should be encouraged. "
  • The altruistic living donor must give informed consent, which can only be obtained if he or she has a proper understanding of the risk involved.

They have this to say about kidney exchange:

  • Paired kidney exchange if permitted by national law is a way of increasing the number of kidney transplants..

Another report, focused specifically on kidney exchange is from Clinical Transplants 2009:247-52, "On chain lengths, domino-paired and unbalanced altruistic kidney donations," by de Klerk M, Zuidema WC, Ijzermans JN, Weimar W. Dept of Internal Medicine - Transplantation, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.

"Abstract: Kidney transplantations with living related and unrelated donors are the optimal option for patients with end-stage renal disease. For patients with a willing--but blood-type or HLA incompatible donor--a living-donor kidney exchange program could be an opportunity. In Asia, the United States and Europe, kidney exchange programs were developed under different conditions, with different exchange algorithms, and with different match results. The easiest way to organize a living-donor kidney exchange program is to enlist national or regional cooperation, initiated by an independent organization that is already responsible for the allocation of deceased donor organs. For logistic reasons, the optimal maximum chain length should be three pairs. To optimize cross-match procedures a central laboratory is recommended. Anonymity between the matched pairs depends on the culture and logistics of the various countries. For incompatible donor-recipient pairs who have been unsuccessful in finding suitable matches in an exchange program, domino-paired kidney transplantations triggered by Good Samaritan donors is the next alternative. To expand transplantations with living donors, we advise integrating such a program into a national exchange program under supervision of an independent allocation authority. If no Good Samaritan donors are available, an unbalanced kidney paired-exchange program with compatible and incompatible pairs is another strategy that merits future development."
PMID: 20524290 [PubMed - in process]

Their conclusion that "the optimal maximal chain length should be three pairs" has certainly not been the U.S. experience: my conjecture is that they are limited to the operating rooms they can organize in a single hospital.

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